The final step of breast reconstruction · New York and New Jersey
Nipple Reconstruction
Nipple reconstruction rebuilds the nipple and areola after a mastectomy. It is the last step of breast reconstruction, and for many patients it is the step that makes the breast look finished. Dr. Steven Ovadia is a board certified plastic surgeon with offices in New York City and New Jersey.
Overview
Finishing the reconstruction
The nipple and areola may be removed as part of the treatment of breast cancer. Nipple reconstruction rebuilds them. It is usually the last step of breast reconstruction, done once the reconstructed breast has healed and settled into its shape.
A new nipple is built from the skin of the reconstructed breast, in a short procedure. Tattooing can then be performed to recreate the coloration of the areola, which is the darker circle of skin around the nipple, and of the nipple itself.
It is optional, and it is an individual decision. Some patients feel that their reconstruction is not finished without a nipple. Others choose a tattoo alone, or nothing at all. The decision can also be made in a delayed fashion, so a nipple reconstruction or a tattoo can be chosen at a later time.
The terms you will hear
Nipple reconstruction
A short procedure
A raised nipple is built from the skin of the reconstructed breast. It gives the breast a nipple with real projection.
Areola tattooing
Color, added later
The areola is the darker circle of skin around the nipple. Once the new nipple has healed, tattooing can be performed to recreate the coloration of the areola and the nipple.
3D nipple tattoo
A tattoo alone, with no surgery
A nipple and areola are tattooed onto the flat skin of the breast, with shading that gives the look of projection. Nothing is raised.
Nipple-sparing mastectomy
When your own nipple is kept
In some mastectomies the nipple and areola can be kept, and nipple reconstruction is not needed. Whether that is possible is decided with your breast surgeon.
Nerve reinnervationYour options
A reconstructed nipple, a tattoo, or neither
There is more than one way to restore a nipple, and no one way is right for everyone. The main difference is whether the nipple is actually raised or is given the look of it.
| Nipple reconstruction with tattooing | 3D tattoo alone | Stick-on nipple | |
|---|---|---|---|
| What it is | A small nipple built from the skin of the reconstructed breast, with color added by tattoo | A tattoo of a nipple and areola, shaded to look raised | A soft silicone nipple held on with adhesive |
| Projection | A raised nipple. Some of its height is lost as it heals | Flat to the touch. The shading gives the look of projection | Raised while it is worn |
| Surgery | A short procedure | None | None |
| How many steps | Usually two: the procedure, then tattooing once it has healed | Usually one or two tattoo sessions | None. It is put on and taken off as you like |
| Over time | The nipple flattens somewhat, mostly in the first months. Tattoo color can fade and be touched up | The color can fade and be touched up | Replaced as it wears |
| Often a fit when | You want a nipple with real projection, and the skin of the breast is healthy | You do not want another procedure, or the skin is thin or has had radiation | You are not ready to decide, or you want a nipple only some of the time |
Choosing one does not rule out the others. A patient who starts with a stick-on nipple can choose a tattoo or a reconstruction later, and a reconstructed nipple that has flattened can be given a tattoo.
The procedure
How a nipple is rebuilt
The nipple is made from the skin that is already on the reconstructed breast. For most patients nothing is taken from another part of the body.
Step 1
The position is chosen
The position of the new nipple is marked on the breast while you are upright. When one breast was reconstructed, it is matched to the nipple on the other side. A pattern of small flaps is drawn at that spot.
Step 2
The nipple is built
The flaps of skin, with a little of the fat beneath them, are lifted, wrapped around each other, and stitched into a small raised nipple. The skin beside it is closed in a fine line.
Step 3 · Later
Color is added
Once the nipple has healed, tattooing can be performed to recreate the coloration of the areola and the nipple. The tattoo also helps hide the fine scars beside the nipple.
The diagram is a general illustration. There are several flap patterns, and the one that is used depends on the skin of your breast and where its scars are.
What else to know about the procedure
Built larger on purpose
A new nipple loses some of its height as it heals. It is made larger than its final size to allow for this, so it looks too big at first.
Anesthesia
Nipple reconstruction can be performed with local anesthesia, or with sedation or general anesthesia. The choice is individualized to your preference, and it is made in consideration of any other procedures being performed at the same time.
One side or both
When both breasts were reconstructed, both nipples are built in the same procedure and placed to match each other. When one was, the new nipple is matched to your own as closely as possible. An exact match may not be possible.
With another procedure
Nipple reconstruction can be paired with some additional reconstructive procedures. Dr. Ovadia discusses with you what makes sense to combine.
The names you may hear
Surgeons name the flap patterns after their shapes. The C-V flap, the skate flap, and the star flap are common ones. They are variations of the same idea.
Other ways to build a nipple
Less often, a nipple is built with a graft, such as part of the nipple from the other breast. This is an option for some patients who had one breast reconstructed.
Tattooing
The areola and its color
A reconstructed nipple is the color of the skin around it. Tattooing can be performed to recreate the coloration of the areola and the nipple. It can follow a nipple reconstruction, or it can be done by itself.
After nipple reconstruction
The second step
Tattooing can be performed once the new nipple has healed, usually a few months after the procedure. Pigment is placed in the skin to recreate the coloration of the areola and the nipple.
A 3D tattoo alone
No procedure
For patients who do not want another procedure, a nipple and areola can be tattooed onto the flat skin of the breast. Shading gives the look of a raised nipple. It can look very realistic, though it is flat to the touch.
Who does the tattooing
A trained specialist
Nipple and areola tattooing is performed by a medical professional or a tattoo artist with special training in it, not by Dr. Ovadia. He can point you toward it once the nipple has healed.
How a tattoo holds up
It can be touched up
Most patients need one or two sessions. The color often looks darker at first and lightens as it heals. It can fade over the years, and it can be touched up.
Tattooing is generally still an option for skin that has had radiation, which makes it a good choice for patients whose skin may not heal a reconstructed nipple reliably.
Timing
When it is done
The breast has to heal and settle before a nipple is placed on it. A nipple placed too early can end up in the wrong position as the breast changes, which is why it is usually not built at the first reconstruction surgery.
After the breast has settled
The usual timing
Nipple reconstruction is usually done at least 3 to 4 months after the last surgery on the breast, whether that was the exchange to an implant, a flap, or a revision.
After radiation
When radiation is part of treatment
Radiation can make the decision about nipple reconstruction a little more complex. It is something to discuss with Dr. Ovadia.
Months or years later
An individual decision
You can decide later. Nipple reconstruction and tattooing can be done years after a mastectomy, including after reconstruction done by another surgeon.
Who it is for
After implant-based reconstruction
Once the tissue expander has been exchanged for the implant and the breast has settled. The skin over an implant can be thin, which is part of what Dr. Ovadia checks when he examines you.
Implant-based reconstructionAfter reconstruction with your own skin and fat
After a flap reconstruction, such as a DIEP flap, the nipple is built from the skin of the flap.
Breast reconstructionAfter a lumpectomy
When a tumor sits directly under the nipple, the nipple may have to be removed with it. It can be rebuilt once treatment is finished.
Oncoplastic breast surgeryA nipple lost after other surgery
A nipple can be lost to a healing problem after other breast surgery, or to an injury. It can be rebuilt in the same way.
Breast revisionReconstruction done elsewhere
You do not need to have had your reconstruction with Dr. Ovadia. He revises and finishes reconstruction first done by another surgeon.
Revising a reconstructionWhen a tattoo may be the better choice
Very thin skin, tight skin, or skin that has had radiation may not heal a new nipple reliably. A 3D tattoo gives the look of a nipple without relying on that skin to heal.
TattooingReal results
Nipple reconstruction before and after
These are Dr. Ovadia's own patients. Each had a nipple rebuilt as the last step of breast reconstruction. Each case notes how far out from surgery the "after" photo was taken.
Before-and-after photographs
This section contains before and after photographs of real surgical procedures.
You must be 18 years or older to view this content.
Recovery
What to expect afterward
The day of the procedure
Nipple reconstruction is an outpatient procedure. You go home the same day.
The dressing
A protective dressing is placed over the new nipple so that nothing presses on it. Dr. Ovadia tells you how to care for it and how long to keep it on.
How it looks at first
The new nipple looks larger, more pointed, and more swollen than it will end up, and it can look red. This is expected. It settles toward its final size over the following weeks and months.
Keeping pressure off
Pressure flattens a healing nipple. For the first weeks, avoid tight bras and sleeping on your chest. Dr. Ovadia tells you what to wear over it.
Discomfort
Most patients have little pain afterward. If another procedure was performed at the same time, Dr. Ovadia goes over what to expect from it.
A break from nicotine
Nicotine affects blood flow to the small flaps of skin that form the nipple. If you smoke or vape, Dr. Ovadia goes over taking a break from nicotine before and after the procedure.
Call the office right away if the new nipple turns dark, purple, or very pale, or if you notice spreading redness, warmth, drainage, or a fever. These are best taken care of early.
A general timeline
This is a general guide. Everyone heals differently. During your recovery, Dr. Ovadia will review your timeline with you.
Over time
How a reconstructed nipple holds up
A reconstructed nipple looks like a nipple, but it does not behave exactly like one. These are the points worth understanding before you decide.
It loses some height
Every reconstructed nipple flattens to some degree. Studies of nipples built from the skin of the breast report that half or more of the early projection can be lost, most of it in the first 6 months. This is why the nipple is built larger than its final size.
If it flattens too much
A nipple that has flattened more than you want can often be built up again with a second small procedure. A 3D tattoo is another option at that point.
Feeling
A reconstructed nipple usually does not have the feeling of a natural nipple. It also does not rise or flatten with touch or cold the way a natural nipple does.
Healing problems
The flaps of skin are small, and occasionally part of a new nipple does not heal. This is more likely in skin that has had radiation, in thin skin, and with nicotine. A small area usually heals with simple wound care, and a nipple can be rebuilt if needed.
Tattoo color
Tattoo color fades with time, faster in some patients than in others. It can be touched up. As with any tattoo, there is a small chance of infection or of a reaction to the pigment.
Follow-up after cancer
Nipple reconstruction does not change your cancer follow-up. Your breast surgeon and oncologists tell you what exams and imaging you need.
Cost and insurance
Insurance coverage
Nipple reconstruction is a stage of breast reconstruction, and it may be covered by insurance. A federal law, the Women's Health and Cancer Rights Act of 1998, requires most health plans that cover mastectomy to also cover reconstruction.
What the law requires those plans to cover
Women's Health and Cancer Rights Act
- All stages of reconstruction of the breast on which the mastectomy was performed
- Surgery and reconstruction of the other breast to produce a symmetrical appearance
New York's insurance law also names tattooing of the nipple and areola as part of breast reconstruction, when it is performed by a licensed health care practitioner, for the plans it regulates. Coverage for tattooing varies more from plan to plan than coverage for the procedure does.
Your plan's deductibles and coinsurance still apply, every plan has its own process for approval, and coverage is not guaranteed.
If you have questions about possible insurance coverage for surgery, call or email us and we will go over it with you.
Your surgeon
Board certified and double fellowship-trained
Dr. Ovadia is board certified by the American Board of Plastic Surgery. After his plastic surgery training he completed two fellowships: gender-affirming surgery and microsurgery at Johns Hopkins, and craniofacial and pediatric plastic surgery at UT Austin / Dell Children's Hospital.
Breast surgery is a large part of his practice. He performs reconstruction after mastectomy, with implants and with the patient's own tissue, and he reshapes the breast at the time of a lumpectomy. Nipple reconstruction is the last step of that work. He also performs it for patients whose reconstruction was first done by another surgeon. He sees patients in New York City and in Jersey City and Millburn, New Jersey.
Questions
Common questions about nipple reconstruction
What is nipple reconstruction?
It is a short procedure that rebuilds a nipple on a reconstructed breast. The nipple is made from small flaps of the skin that is already on the breast. Tattooing can then be performed to recreate the coloration of the areola and the nipple. It is typically the last step of breast reconstruction, and it is optional.
When can I have nipple reconstruction?
Usually at least 3 to 4 months after the last surgery on the breast, once the breast has healed and settled into its shape. A nipple placed too early can end up in the wrong position as the breast changes. It is an individual decision, and it can be made in a delayed fashion: a nipple reconstruction or a tattoo can be done years later.
What kind of anesthesia is used?
Nipple reconstruction can be performed with local anesthesia, or with sedation or general anesthesia. The choice is individualized to your preference, and it is made in consideration of any other procedures being performed at the same time.
How long does it take, and how long is the recovery?
Nipple reconstruction on its own usually takes less than an hour. When it is combined with other procedures, the operation takes longer. You go home the same day. A protective dressing covers the nipple at first. The nipple has usually healed by 4 to 6 weeks, and it keeps settling for several months.
Will the new nipple have feeling?
A reconstructed nipple usually does not have the feeling of a natural nipple, and it does not respond to touch or cold. A mastectomy removes many of the small nerves that give the skin of the breast its feeling. Some feeling in the skin of the breast can return over time.
Will the new nipple stay raised?
It stays raised, but it loses some of its height as it heals. Studies report that half or more of the early projection can be lost, most of it in the first 6 months. For this reason the nipple is built larger than its final size. A nipple that flattens more than you want can often be built up again.
What is a 3D nipple tattoo?
It is a tattoo of a nipple and areola on the flat skin of the breast, with shading that gives the look of projection. There is no surgery. It can look very realistic, though it is flat to the touch. The color can fade over the years and can be touched up.
Do I need both a reconstruction and a tattoo?
No. Many patients have a nipple built and then have tattooing to recreate the coloration of the areola. Some choose a 3D tattoo alone, with no procedure. Some choose a reconstructed nipple without a tattoo, and some choose neither. Dr. Ovadia goes over the options with you.
Can I have nipple reconstruction after radiation?
Radiation changes the skin of the breast, and it can make the decision about nipple reconstruction a little more complex. It is something to discuss with Dr. Ovadia at your consultation.
Can a nipple be reconstructed over an implant?
Yes. Nipple reconstruction is done after implant-based reconstruction and after reconstruction with your own skin and fat. The skin over an implant can be thin, which is part of what Dr. Ovadia checks when he examines you.
I had my reconstruction years ago, with another surgeon. Can I still have a nipple reconstructed?
Yes. Nipple reconstruction and tattooing can be done years after a mastectomy, and you do not need to have had your reconstruction with Dr. Ovadia. Bring any records you have from your earlier surgery.
My nipples were kept at my mastectomy. Is this procedure for me?
No. After a nipple-sparing mastectomy your own nipple and areola are kept, so there is nothing to rebuild. Feeling in a kept nipple is a separate subject. Nerve reinnervation, which is aimed at bringing feeling back, is done at the same operation as the mastectomy and is described on the implant-based breast reconstruction page.
What if I am not sure I want a nipple?
Then you can wait. Nipple reconstruction is optional and an individual decision, and it can be done later. Some patients try a stick-on silicone nipple first, which can be put on and taken off. Others decide they are comfortable without one.
I had a mastectomy without reconstruction. Can I still have a nipple?
A nipple and areola can be tattooed onto a flat chest, and for some patients a nipple can be built. Dr. Ovadia goes over what is possible after he examines you.
What are the risks?
The most common issue is that the nipple flattens more than expected. Occasionally part of a new nipple does not heal, which is more likely in skin that has had radiation, in thin skin, and with nicotine. Infection can happen, as with any procedure. The position or size may not match the other side exactly. Each of these can usually be improved with a small revision or with tattooing.
Is nipple reconstruction covered by insurance?
Nipple reconstruction is a stage of breast reconstruction, and it may be covered. Federal law requires most health plans that cover mastectomy to cover all stages of reconstruction. Your plan's deductibles and coinsurance still apply, and coverage is not guaranteed. Coverage for tattooing varies more from plan to plan. If you have questions about possible insurance coverage for surgery, call or email us and we will go over it with you.
Can I have a consultation without coming to the office?
Yes. Phone and video consultations are available, in addition to in-person visits in New York City, Jersey City, and Millburn, New Jersey.
Next step
Start with a consultation
Dr. Ovadia will examine you, go over your options, and explain what he recommends and why. If your reconstruction was done by another surgeon, bring any records you have from that surgery.
225 Broadway, Suite 3100, New York, NY
377 Jersey Ave, Suite 440, Jersey City, NJ
90 Millburn Ave, Suite 206, Millburn, NJ
Phone and video consultations available · info@ovadiaps.com